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Tuesday, April 25, 2017

 
 
 

 
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Posts Tagged ‘treatment’

Important Changes are Coming to Your Car Insurance Policy

While no one likes to pay car insurance premiums, these are meant to provide you with peace of mind in the event that you are ever injured in a motor vehicle accident. It is very important that you plan for the worst-case scenario so that you will have the funds that you need to cover your medical, rehabilitation, attendant care, and other expenses if you are seriously or catastrophically injured.

As of June 1, 2016, all new or renewed automobile insurance policies written in Ontario will significantly lower the standard amount of accident benefits available to an individual who is injured in a motor vehicle accident.

Accident Benefits are available to anyone in Ontario injured in a motor vehicle accident, regardless of fault.

The most significant changes to the standard policy will be as follows:

Benefit Current Policy New Policy You can choose1
Medical and Rehabilitation for non-catastrophic injuries $50,000 These benefits have been combined and reduced to $65,0000 total Increase the benefit to $130,0002 total
Attendant Care for non-catastrophic injuries $36,000
Medical and Rehabilitation for catastrophic injuries $1,000,000 These benefits have been combined and reduced to $1,000,000 total An addition $1,000,000 for a total of $2,000,0002 for catastrophic injuries
Attendant Care for catastrophic injuries $1,000,000
Medical, Rehabilitation and Attendant Care, all injuries Not applicable Not applicable Increase the combined non-catastrophic benefit to $1,000,000 and the combined catastrophic benefit total to $2,000,0002 3
  1. If you have previously chosen to purchase these optional benefits check your policy – they may have changed to reflect amounts available in new options.
  2. Medical, Rehabilitation and Attendant Care benefits for minor injuries are fixed at a maximum limit of $3,500.
  3. If you purchase both the additional Medical, Rehabilitation and Attendant Care benefit for catastrophic injuries and for all injuries, the total eligible benefit amount for a catastrophic impairment would be $3,000,000. There are additional optional coverages available to increase your income replacement benefit from the basic maximum of $400.00 per week, in case you are unable to work. You can also get coverage for caregiver and housekeeping and home maintenance benefits for non-catastrophic injuries.We strongly advise you to discuss your policy with your insurance broker or agent before your policy is renewed after June 1, 2016, to ensure that your needs are met. While no one wishes the worst, it is good to have the coverage if it is ever needed. Many of our clients will attest to this.

There are additional optional coverages available to increase your income replacement benefit from the basic maximum of $400.00 per week, in case you are unable to work. You can also get coverage for caregiver and housekeeping and home maintenance benefits for non-catastrophic injuries.

We strongly advise you to discuss your policy with your insurance broker or agent before your policy is renewed after June 1, 2016, to ensure that your needs are met. While no one wishes the worst, it is good to have the coverage if it is ever needed.  Many of our clients will attest to this.

New Decision Clarifies Insurer’s Examination Requirements

In the decision, Larry Ward and State Farm Mutual Automobile Insurance Company [FSCO A14-010161], Arbitrator Chuck Matheson decided on a preliminary issue as to whether an insured, Mr. Larry Ward, was precluded from proceeding to arbitration on a number of issues due to his non-attendance for insurer’s examinations, which are required under Section 44 of the Statutory Accident Benefits Schedule (SABS).

One of the factors considered by Arbitrator Matheson was whether or not State Farm provided medical or other reasons for the insurer’s examinations.  The arbitrator interpreted the requirement to be that, “…the medical reasons test must tell the Applicant, in an unsophisticated way, why the tests [insurer’s examinations] are reasonable and necessary.”  The words “reasonable and necessary” are new to the consideration of what is required for a medical reason required by an insurer.

The decision also confirms that, just because an insurer has not approved particular treatment or an assessment (for instance, if it is funded by OHIP), does not mean that they are not required to pay for transportation to and from them.  It also confirms that an OCF-18 Treatment and Assessment Plan is not required for goods or services under $250.00, as well as for medications prescribed by a regulated health professional.

Arbitrator Matheson also concluded that case management services, while subject to submission on a treatment plan, are not subject to an insurer’s examination.  He notes that,

I accept the Applicant’s interpretation of section 14 that the “virtual account” called medical and rehabilitation benefits shall pay for the specified benefits listed in sections 15, 16 and 17. It does not mean, however, that section 17’s case manager benefit is in fact a Medical or Rehabilitation Benefit, per se. The legislature severed the case manager because it is not a specified Medical or Rehabilitation Benefit. The case manager’s function is to coordinate the specified benefits of sections 15 and 16 in order help the insured person to attend and claim said specified Medical/Rehabilitation and/or Attendant Care Benefits for a catastrophically impaired person.

This decision can be read in its entirety by clicking on the link below.

Ward and State Farm – Medical Reason, Transportation

FSCO Announces Changes to SABS, Attendant Care Hourly Rates

The Financial Services Commission of Ontario (FSCO) has announced major changes to the Statutory Accident Benefits Schedule (SABS), effective June 1, 2016.

These changes include the following:

  • Medical and Rehabilitation Benefits, as well as Attendant Care Benefits, will be combined with respect to limits
    • For non-catastrophic claims, the maximum will be $65,000.00 for up to five years from the date of accident
    • For catastrophic claims, the maximum is $1,000,000.00, over a lifetime
  • Non-Earner Benefit – $185.00 per week, payable after four weeks but only to a maximum of two years following the accident
  • Catastrophic Impairment Designation – a whole new criteria for determining catastrophic impairment will be in force

FSCO has provided a new Attendant Care Hourly Rate Guideline, reflecting an increase to $11.25 per hour, effective October 1, 2015.

The Professional Services Guideline fees for 2015 remain unchanged from the previous year.

The bulletin can be read in its entirety by clicking on the link below:

http://www.fsco.gov.on.ca/en/auto/autobulletins/2015a/Pages/a-06-15.aspx

Costs for Examination for CAT Assessment, Form 1 Completion and Disability Certificate Not Out of Med-Rehab Limits

A recent decision by the Financial Services Commission of Ontario (FSCO) confirms that the costs for completion of a catastrophic assessment are not subject to the medical and rehabilitation benefit limits.

In Lee-Anne Henderson and Wawanesa Mutual Insurance Company [FSCO A14-001758], Arbitrator Patrick Bowles was asked to consider whether or not this was the case.  The Applicant, Ms. Henderson, had requested that the costs for the completion of a catastrophic assessment be paid by the insurer.  Wawanesa denied payment, stating that Ms. Henderson had reached the maximum payable for medical and rehabilitation benefits in the amount of $50,000.00, therefore there was no further benefits available to fund the assessments.

Arbitrator Bowles accepted Ms. Henderson’s argument that the only assessments that are subject to the medical and rehabilitation benefit limits are ones for the purpose of claiming a medical and rehabilitation benefit.  Since a catastrophic determination is not for the purpose of a benefit per se (rather, it is for a determination on the amount of benefits available), it is not subject to the limits, and should properly be allocated as a claims expense by the insurer.

While it was not directly considered in this decision, it follows that the costs for completion of an Attendant Care Needs Assessment (Form 1), as well as a Disability Certificate (OCF-3) are also not subject to payment under the medical and rehabilitation benefits, as they are for an attendant care benefit and for specified benefits, respectively.

If an insurer is claiming that the medical and rehabilitation benefits have reached the limits, it is helpful to obtain an itemized listing of all payments made to determine if any payments have been incorrectly allocated.  This could free-up additional funds that may be needed by an insured for treatment.

This decision can be read in its entirety by clicking on the link below.

Henderson, Lee-Anne and Wawanesa – COE for CAT not in MR benefit limits

Client Involved in an “Accident”: FSCO Arbitrator

Our firm successfully represented a client in an arbitration hearing through the Financial Services Commission of Ontario (FSCO).

D.C. (initials are being used, at our client’s request) was riding his bicycle in Burlington, Ontario, when an unidentified vehicle struck either him or his bike and he fell to the ground.  D.C. does not recall the details of the actual impact, but did recall being struck by a white vehicle.  The vehicle did not stop and there were no known witnesses.

D.C.’s bicycle was damaged to the point that he could not ride it home.  The damage was seen by his wife and his brother-in-law.  Since it would cost more to repair the bicycle than to buy a new one, it was thrown out in the trash.  D.C. was unaware that, because his injuries were caused by a motor vehicle, he was eligible for accident benefits, so the bicycle was not kept as evidence.  Additionally, the incident was not reported to police, as D.C. did not think that anything could be done since the vehicle that hit him was unknown and there were no witnesses.

He went home, scraped and bruised, but otherwise felt fine.  The next morning his wife found him unconscious in bed and he was rushed to hospital by ambulance, where he was found to have suffered a subdural hematoma (acquired brain injury), which necessitated a full craniotomy.  Several months later, in the course of his rehabilitation, he was advised to seek legal advice, since he could be eligible for accident benefits.  D.C. called, and then retained, Smitiuch Injury Law.

An accident benefits claim was started with D.C.’s insurer, Aviva Canada.  Aviva accepted D.C.’s accident benefits claim, accepted his injuries as being catastrophic, and began paying accident benefits.  However, once some benefits were denied and were then disputed, Aviva took the position that D.C. was not involved in an “accident”, as defined in the Statutory Accident Benefits Schedule (SABS).

Luke Hamer, assisted by Chris Jackson (Accident Benefits Manager), represented D.C.  Both the client, his wife, and his brother-in-law were interviewed and all were in agreement with the type of damage that was done to the bicycle.  Based on their description, a forensic engineer was retained, who was then able to provide an opinion that the type of damage to the bicycle described by the witnesses could only have been caused by a motor vehicle.

Based on the testimony of the witnesses, the arbitrator ruled in favour of D.C.  As a result, he will continue to be eligible to receive accident benefits, which he will likely require for the rest of his life.

The redacted arbitration decision can be read it its entirety by clicking on the link below.

DC and Aviva Canada (Redacted) dated July 3 2015

FSCO Announces Amendments to SABS, Service Provider Regulations, etc.

The Financial Services Commission of Ontario (FSCO) has released a bulletin announcing changes to the Statutory Accident Benefits Schedule (SABS), service provider regulations, administrative penalties and eligibility for transportation expenses.

Below are the highlights:

  • Effective December 1, 2014, both licensed and unlicensed service providers and provide goods and service to auto insurance claimants.  Licensed service providers can receive payment directly from insurers, which unlicensed service providers cannot.  Unlicensed providers must complete the OCF-21 form (Auto Insurance Standard Invoice) on HCAI, print it, and provide a copy to the claimant.
  • Effective January 1, 2015, the current interest rate of 1% per month, compounded monthly, will continue to apply.  However, once a mediation proceeding has commenced, the interest rate will then change to the prejudgement interest rate described in the Courts of Justice Act for past pecuniary loss.  This will be calculated from the date on which a mediation proceeding commenced and ending on the date a settlement is reached or a decision is issued.  The current prejudgement interest rate is 1.3% per annum.
  • It is now considered to be an unfair or deceptive act or practice if an unlicensed provider advertises as a licensed provider.
  • There is now an exemption allowing licensed service providers to seek direct payment for a listed expense provided under the SABS from anyone other than an insurer.
  • Specifies penalties for non-compliance with the newly added requirements.
  • Reminds insurers that “authorized transportation expenses” apply only expenses incurred by the insured person or an aide.  It notes that service provider mileage costs are subject to FSCO’s Professional Service Guidelines, which states that insurers are not liable for any other costs beyond what is permitted under the Professional Service Guideline.

The bulletin can be read in full at the following link:

http://www.fsco.gov.on.ca/en/auto/autobulletins/2014/Pages/a-14-14.aspx

FSCO Releases New Professional Services Guideline

The Financial Services Commission of Ontario (FSCO) has released an updated Professional Services Guideline, which applies to expenses related to services provided by health care providers rendered on or after September 6, 2014.

A copy of the new guideline can be found at the link below.

2014 FSCO Fee Guidelines

New OCF Forms to be used effective November 1, 2014

The Financial Services Commission of Ontario (FSCO) has released two bulletins with new forms to be used for accident benefits claims, effective November 1, 2014.

The new forms include the Application for Accident Benefits (OCF-1), Treatment and Assessment Plan (OCF-18), Auto Insurance Standard Invoice (OCF-21) and the Treatment Confirmation Form (OCF-23).

In a bulletin released by FSCO it was indicated that the reason for these changes is “to improve transparency and clarity regarding data analytics and pooling of information to detect fraud.  The OCF-23 has also been revised to accommodate Service Provider Licensing.”

These new forms can be downloaded at the links below:

OCF-1 – Effective Nov 1, 2014

OCF-18 – Effective November 1, 2014

OCF-21 – Effective November 1, 2014

OCF-23 – Effective November 1, 2014

Smitiuch Injury Law to be Gold Sponsor at Hamilton Health Sciences Centre’s 21st Annual Conference on Neurobehavioural Rehabilitation in Acquired Brain Injury

Smitiuch Injury Law is pleased to be a Gold Sponsor for this important event.  It will be held on May 8 and 9, 2014, at the Hamilton Convention Centre.

We encourage all ABI Rehabilitation Professionals, Psychologists, Physicians, Program Planners, Insurance and Advocates to attend.

You can obtain a copy of the brochure by clicking on the link below:

ABI_Broch2014_mailer_final_lo

FSCO Issues Revised Minor Injury Guideline and OCF-18

The Financial Services Commission of Ontario (FSCO) has released a revised Minor Injury Guideline (MIG) as well as a revised Treatment and Assessment Plan (OCF-18).  Both of these become effective February 1, 2014.

These revisions reflect the changes to be made to the Statutory Accident Benefits Schedule (SABS) on February 1, 2014.

To access the FSCO Bulletin, as well as the documents, click here.

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